MEDICARE: S P A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	DO1528	NV

General Provider Information

NPI Number	:	1427453455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S P A

Provider Business Mailing Address
First Line	:	20 E SERENE AVE
Second Line	:	UNIT 106
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-3766
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 E SERENE AVE
Second Line	:	UNIT 106
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-3766
Country	:	US
Telephone Number	:	630-890-2641
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AMIT VALERA
Credential	:	DO
Telephone Number	:	630-890-2641

Provider Enumeration Date	:	11/04/2014
Last Update Date	:	11/04/2014

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Directions to “S P A ” Practice Location

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